Effects of decentralization on the functionality of health facility governing committees in lower and middle-income countries: a systematic literature review

ABSTRACT Background Health facility governing committees (HFGCs) were established by lower and middle-income countries (LMICs) to facilitate community participation at the primary facility level to improve health system performance. However, empirical evidence on their effects under decentralization reform on the functionality of HFGCs is scant and inconclusive. Objective This article reviews the effects of decentralization on the functionality of HFGCs in LMICs. Methods A systematic literature review was conducted using various search engines to obtain a total number of 24 relevant articles from 14 countries published between 2000 and 2020. Inclusion criteria include studies must be on community health committees, carried out under decentralization, HFGCs operating at the individual facility, effects of HFGCs on health performance or health outcomes and peer-reviewed empirical studies conducted in LMICs. Results The study has found varied functionality of HFGCs under a decentralization context. The study has found many HFGCs to have very low functionality, while a few HFGCs in other LMICs countries are performing very well. The context and decentralization type, members’ awareness of their roles, membership allowance and availability of resource to the facility in which HFGCs operate to produce the desired outcomes play a significant role in facilitating/limiting them to effectively carry out the devolved duties and responsibilities. Conclusion Fiscal decentralization has largely been seen as important in making health committees more autonomous, even though it does not guarantee the performance of HFGCs.

Effects; health facility governing committees; functionality; lower and middle-Income countries; systematic literature review

Background
The Alma Ata Declaration of 1978 identified community participation in health service delivery as a critical component of improving Primary Health Care (PHC). It is advocated for providing opportunities for health service users to directly participate in the design, implementation, and assessment of healthcare facility operations, to improve healthcare responsiveness, sustainability, and efficiency [1,2]. To incorporate communities in the planning, implementation, and evaluation of primary health care services, a variety of mechanisms have been developed by lower and middle-income countries (LMICs) [3]. The introduction or adoption of Health Facilities Governing Committees (HFGCs), also known as Community Health Committees, Village or Ward Health Committees, was one of the mechanisms utilized to improve community engagement in primary health care facilities [4]. These HFGCs, despite various terminologies used to name them in different countries, are community governance structures made up of community members who are responsible for representing the community in the planning, implementation, and management of health service delivery in primary health care facilities. Since the 1980s, the HFGCs have been working in various Health Sector Reforms (HSR) contexts, depending on the country's distinctive path [5,6]. Some countries have combined community participation with decentralization measures, whereas others have not. Following the establishment of these HFGCs, the global health community has been eager to learn whether or not the existing HFGCs have achieved the desired health outcomes. The decentralized health system is defined as the transfer of major decision-making powers and responsibilities for health services, such as planning, budgeting, and financial management from the central government or a large unit of local government to a smaller unit that is closer to the community [7][8][9][10]. Decentralization refers to a variety of measures, including de-concentration, in which authority and responsibility are transferred from the national level to regions or districts within the same ministry; Devolution, in which authorities and responsibilities are delegated to lower-level government structures; Delegation, in which semi-autonomous agencies are created to carry out functions that were previously controlled by the Ministry of Health; and Privatization, in which private owners assume responsibility and control [3,11]. Decentralization is adopted in the health sector to improve the performance of the health system, which improves the delivery of health services.
In the context of decentralization, it is widely accepted that community participation in primary health care facilities through various structures, such as HFGCs, can be functional enough in accomplishing their devolved functions and yield desired outcomes [11][12][13]. The goal of incorporating community involvement into primary health care was to increase citizen participation in the design, execution, and assessment of health service delivery in institutions such that the services generated reflected community preferences and needs. As a result, community members are expected to provide input during the management and governance of health facilities to make decisions that address community health concerns and promote community health, albeit this may not be the case in all health facilities. Indeed, under decentralized reform, HFGCs composed of community representatives elected or chosen by their community are likely to have a significant impact on health service delivery. This is because decentralization provides HFGCs with more options (functions and powers) and creates a conducive environment for them to carry out their duties [5,14]. As a result, the HFGCs are given crucial authority and decisions, such as revenue collection and expenditure, planning and administration of the health facility's performance. The notion is that by forming HFGCs made up of community members and decentralized with additional functions and decision-making capabilities to govern health facilities, the community will be better served. HFGCs are better positioned and have more discretion than the central government to make new and more innovative judgments that are locally focused and maximize people's preferences. Alma Ata's dedication to establishing community engagement is congruent with the decentralization concept.
Empirical research, on the other hand, reveals that implementing decentralization in primary health care institutions and devolving authority to lower-level governance structures may not inevitably influence community engagement or HFGCs functionality. As Bossert and Abimbola [3,5] argue, agents devolved with discretionary powers and functions may choose not to exercise or take advantage of their devolved capabilities, continuing to behave and operate as they did before decentralization. As a result, certain agents, such as HFGCs, may not effectively carry out or be functional in accomplishing their devolved powers and duties to achieve the desired health objectives. As part of community participation in health care delivery, HFGCs would be expected to use devolved authorities to manage and govern primary health facility operations.
Despite the adoption of community participation in health service provision, empirical evidence on the functionality of HFGCs under decentralization as a part of community participation at the primary health care facility is lacking. The present empirical evidence is based on a small number of case studies or countries, which do not reflect the reality of the functionality of HFGCs in improving health outcomes in a decentralized setting. Three studies, for example, looked at the empirical evidence of the impact of decentralization on health outcomes [4,15,16]. Much of the research looked at the impacts of decentralization on health outcomes as well as the impact of accountability measures. The flaw in these empirical studies is that they did not look at the functionality or performance of HFGCs in a decentralized setting. Given the relevance of HFGCs in enhancing health system performance, a systematic review based on broader empirical research from lower and middle-income countries is required to assess the effect of decentralization on the functionality of HFGCs.

Methods
A systematic literature review was conducted on empirical studies based on the protocols established by Cochrane Methods [17] and guided by the criteria articulated by PRISMA for systematic review reporting in the field of health [18,19]. The protocol and PRISMA are the following processes to be indicated: data search strategy, selection process, quality assessment, data extraction, result, data synthesis

Data search strategy
We conducted a literature search from the different databases, such as PubMed, MEDLINE, JSTOR, Willey, Emerald Insight and Taylor & Francis to get empirical articles published from 2000 up to 2020. Articles published between 2000 and 2020 were selected because many lower and middle-income countries implemented decentralization in the 1990s, therefore by 2000 many countries were implementing it, and the impact of decentralization started to be realized. A manual search was also conducted on different web pages to get evaluation reports from different institutions. The selected databases were chosen because they publish public administration content; therefore, they adequately offered the needed articles for this study.
The goal of this study was to see how decentralization affected the functionality and efficacy of Health Facility Governing Committees in terms of enhancing health system outcomes. Because the amount to which powers are devolved to HFGCs varies by country under decentralization, this study looked at the functions of HFGCs in the context of the powers that have been devolved in the given country. These committees are responsible for guaranteeing the availability of critical medical equipment and pharmaceuticals, planning, budgeting, mobilizing and administering facility money, managing health personnel, and organizing communities to join community health funds, among other things. Since the term Health Facility Governing Committees is used differently in lower and middle-income countries, with some countries referring to them as health facility committees, community health committees, health user committees, and village or ward committees, this study searched for articles using similar terms in all terms amounting to community health committees. Words like 'HFGC', 'Village health committees' 'community health committees' 'effectiveness,' 'functionality,' 'performance,' 'impacts,' 'outcomes,' 'effects,' 'outputs' and 'decentralization' were paired with terms like 'effectiveness of health facility committees' or 'performance of health facility governing committees' to find articles.

Selection process
All studies of various designs were eligible for the evaluation process if they met established inclusion and exclusion criteria. The following criteria were used to select eligible articles: the article had to be about health facility governing committees, (ii) it had to be original published articles or peer-reviewed articles, and (iii) it had to be conducted in lower and middle-income countries as defined by the World Bank [20], (iv) written in English language (v) the study's goal was to determine the effectiveness, functionality, performance, or effects of the governing committee of a health facility on improving health outcomes. (vi) The factor of time (from 2000 to 2020). Papers that satisfied the aforementioned criteria were chosen and subjected to quality control and data selection.

Quality assessment
To assess the quality of the selected studies, the researchers used a variety of assessment tools or criteria. The procedure for a systematic review of the literature was used for quantitative investigations [21] while for qualitative studies, the Critical Assessment Skills Program (CASP) was adopted https://casp-uk.b-cdn.net/wp-content/. The CASP indicators were utilized to choose which qualitative research should be included in the study, with 14 out of 29 qualitative studies matching the CASP requirements. The 14 studies chosen are those with a quality rating of more than 75% (high quality), of which 6 were chosen, and those with a rating of more than 50% but less than 75% (medium), of which 8 were chosen, and those with a rating of less than 50% (poor quality), of which 15 were not. These two assessment tools assisted in ensuring that the selected studies were methodologically appropriate for the investigation, that biases were avoided, and that their flaws were addressed. After the quantitative study assessment, the indicators 'strong,' 'moderate,' and 'weak' were utilized to represent the quality of the selected quantitative study.

Data extraction
We retrieved information about the functionality or performance of HFGCs in carrying out their devolved powers and responsibilities at the facility level in the context of decentralization from each selected paper. The extraction was directed by the inclusion criteria set forth in order to successfully extract relevant information for the aim of this study. As a result, papers published before 2000 and after 2020 were eliminated, leaving just papers published between 2000 and 2020. We then looked at data from studies that looked at the functionality or performance of HFGCs in primary health care facilities exclusively (health centers, dispensaries, and health posts) that had been decentralized and given certain powers and responsibilities. This allowed information about certain HFGC's responsibilities or tasks in a given facility to be extracted. We extracted information about the parameters influencing HFGC decentralized functionality or performance, as well as the health outcomes attained as a result of the HFGC functionality or performance, from each research.

Included studies
The course of the literature review in this study is depicted in Figure 1. The method began with a total of 602 articles and titles being retrieved from various search engines, after which 25 articles were identified as duplicates from the 603 identified articles and titles, leaving the study with 575 articles and titles. Relevant articles and titles about decentralization in health care provision were evaluated for relevance; we ended up with 229 articles and titles following the screening. After reading the abstracts to evaluate if they were relevant to the study topic, 151 papers were eliminated, leaving 78. The reasons for the deletion are listed above. After a careful analysis, 24 articles qualified for extraction since they satisfied the predetermined criteria. Table 1 summarizes the articles qualified for extraction.

Data synthesis
The studies were divided into four categories: the first dealt with the membership of HFGCs in primary health care institutions, the second with the roles devolved to the HFGC as a result of decentralization, and the third with the roles devolved to the HFGC as a result of decentralization. The third category dealt with HFGC functionality in a decentralized environment, the fourth with the factors that influenced HFGC functionality, and the final category dealt with the effects of HFGC functionality on health service delivery. A meta-analysis was not performed in this investigation due to a number of limitations, including the research designs employed and the outcome measurement criteria used in each study. The quality assessment tool was adopted to ascertain the validity of the reviewed empirical studies since the instrument is recommended for covering empirical studies used in international development settings [22] The composition of health facility governance committees under decentralization Many HFGCs were discovered to be made up of community representatives, reflecting community participation in the management and administration of health service delivery in many decentralized limits. The importance of community participation is mirrored in the composition of HFGCs, with community representatives accounting for the majority of HFGCs in the research examined. The following research, for example, has highlighted community representatives in HFGCs [23,24,27,28,30,32,37,41,42,44,47]. Health facility in charges or health facility staff have also been mentioned to be a member of the HFGCs who in many committees become HFGC secretaries [26,28,32,37,38,42]. Village governments or members of the local government in  some countries are included in the HFGCs, as has been highlighted by the governing guidelines [26,28,40,42,45]. Gender representation has not been left out in the composition of HFGCs in many countries, this is evidenced by the special requirement of gender representation among community representatives in the HFGCs [26,28,40,45,48].

The roles and powers of health facility governing committees under decentralization
The HFGCs were found to have been devolved with many responsibilities and roles to fulfill in the course of governing and administering primary health facilities, according to the extracts investigations. Some of the responsibilities include managing and overseeing facility operations [23,25,26], to articulate community interest and address community health matters [23,26,30,33,37,42], participating in planning and budgeting [23,26,31,38,42,45,49,50]. Other common functions of HFGCs are to mobilize facility resources such as funds and other materials [23,25,26,33,37,38], managing the performance of health workers, including hiring and firing [23,26,40] and facilitate feedback to community and health facilities [23,26,31,33,38].

The functionality of health facility governing committees in the decentralized health system
The extracts reviewed have highlighted the functionality of HFGCs as a means of facilitating community participation in the decentralized context. The results indicate that the functionality of HFGCs in many countries is still very low and below the expectation of pioneers of health reforms even though in other countries HFGCs are functioning well. Some studies that have shown that HFGC functionality under the decentralization context is very limited [25,27,28,30,34,36,40,41,43,45]. On the other hand, other studies have found that HFGCs are functioning very well and accomplishing their duties and responsibilities to a large extent [23,24,26,29,[31][32][33]37,38,42,44,46]. Indeed, the studies have highlighted some of the roles which are performed well by the majority of the HFGC such as engagement in the planning and budgeting process [23,24,26,35,38,46]. Monitored performance of health workers [31][32][33]37], finding solutions to the community health problems [26,32,37,42]. Other HFGCs were doing well in mobilizing and sensitizing communities on health programs [24,26,42]. Meanwhile, HFGC has been found to be ineffective in other circumstances, failing to engage in budgeting and planning, linking community and health facilities, convening HFGC meetings, and making other significant decisions that could improve health service delivery [25,30,34,40,41].

Factors influencing the functionality of health facility governing committees under decentralization
A variety of factors have been linked to the functionality of the HFGCs in developing nations' decentralized health systems. These variables are linked to both positive and bad functionality in various ways. The highlighted factors found to be associated with HFGCs functionality are HFGC membership allowance [23,24,26,32], awareness on the HFGC roles and powers [23,29,30,33,34], introduction of fiscal decentralization (23,24,28). Other factors are Training to committees [27,30,43], availability of resources [23,24,26,28,42], context in which the facility operates [30,32,36,43,45]. Furthermore, social norms, leadership, HFGC selection and composition, and even the ways of recruiting members were found to be linked to HFGC functionality.

Discussion
In lower-and middle-income countries, expanding decentralization in primary health care institutions is proposed as a foundation for improving community engagement in the management and control of health service delivery. Indeed, decentralization is claimed to give community health structures like HFGCs considerable powers and functions, empowering them and increasing the depth of engagement in boosting health service delivery at the facility level. This is in line with the Alma Ata Declaration's aim of community participation in the design, implementation, and administration of their health care. Therefore, it is expected that decentralization would positively influence the functionality of HFGCs and be able to deliver their mandates. To determine the functionality of HFGCs in the decentralized health system in primary health care, we conducted a systematic literature review. Twenty-four studies were reviewed from 13 countries in 3 regions. Linked matters relating to the functionality of HFGCs were assessed including the roles of HFGCs, the membership of the HFGCs, the functionality of HFGCs, the factors influencing the functionality of HFGCs and the effects of HFGCs on health outcomes under decentralization. In a decentralized setting, we discovered functionality inconsistency among HFGCs in lower-and middle-income countries, with the majority of HFGCs having limited functionality even after decentralization.
The study discovered that HFGCs in many nations from various locations, such as Asia, Africa, and South America, had similar compositions, with community representatives and other government staff in all of them. These committees have found that the bulk of their members come from communities with few government officials, such as village or local government representatives, and facility employee representatives, to reflect the community. This means that the HFGC was created to increase community participation in defining health service delivery and to be responsive to community needs and preferences. The survey also discovered that the majority of HFGC roles are similar across countries and locations. In many countries, the role of the HFGC is to connect communities with health facilities, participate in planning and budgeting, approve facility expenditure, mobilize and sensitize communities about various health programs, and manage health worker performance, including hiring and firing some clerical staff. Other responsibilities include directing facility administration, managing health facility finances, discussing and addressing community health concerns, and managing health facility finances.
Decentralization of powers and functions to HFGCs at the primary health care facility level does not guarantee effective HFGC functioning or increased community participation at the facility level, according to the study's findings. This is because, in many nations, HFGCs have been shown to have a variety of performances in their decentralized roles. After decentralization, it was envisaged that HFGC would be able to carry out its tasks and responsibilities more effectively and have an impact on health service delivery. However, when it comes to reality, the results show that this is not the case. This is in line with Bossert's [5] belief that giving grassroots organizations more decision-making power does not guarantee that change will occur. Many HFGCs have discovered that various circumstances are preventing them from realizing their full potential. For example, HFGCs fail to fulfill their responsibilities because they are unaware of the scope of their responsibilities and powers, while others are working with insufficient resources, lack of support from higher levels, and small committee composition. Allowance to members of the HFGCs has been found to be critical in encouraging them to carry out their responsibilities, even though members declare that they are working freely for the benefit of the community.
The 'allocative efficiency' principle states that because of the information advantage that subnational institutions or facility-level institutions have over the national government, they can improve health outcomes through proper resource allocation. However, the situation in some health facility committees is a little different. These committees have been proven to have fewer effects on the performance of the health system than expected, some of which contradict the allocative efficiency thesis. The performance variances or efficacy of health facility committees in low-and middle-income nations can be explained by a variety of factors. The decentralization environment that different lower and middleincome nations have experienced or implemented is one key influence.

Conclusion
Decentralization of the health system promised the empowerment of subnational health institutions, which would be particularly effective in carrying out their tasks in enhancing primary health care outcomes. However, reality differs from assumptions, as many studies have shown that decentralization alone cannot improve health service delivery at the primary health care facility level by influencing community engagement and the functionality of community governance structures, such as HFGCs. Instead, the setting in which HFGCs function, as well as the adoption context for decentralization, is critical to achieving the benefits of HFGCs and decentralization in general.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Funding information
The author(s) reported that there is no funding associated with the work featured in this article.

Author contribution
Anosisye Kesale conceptualised, wrote the introduction, methodology and searched the literature and did the analysis. Mikidadi Muhanga participated in writing the manuscript, methodology, data analysis, discussion and supervision. Christopher Mahonge engaged in conceptualization, methodology, data collection, data analysis and discussion

Ethics and Consent
Not Applicable

Paper context
Governing committees for health facilities were formed to encourage community participation in the delivery of health services. Decentralization is thought to have a significant impact on the HFGCs' ability to govern service delivery. The findings reveal that HFGCs have promising effects, despite the fact that they are still far from fulfilling their full potential. These committees should be capacitated in their tasks and powers and given full autonomy in order to realize their full potential.